Greendale Park Nursing and Rehab

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility did not ensure 1 (R2) of 1 residents reviewed for self-administration of medications had a physician order to self-administer and for the medication.*R2 was observed with Melatonin 5mg at the bedside and did not have a physician order for Melatonin 5mg or an order to self-administer medication.Findings include:The facility's policy titled Self-Administration of Medications effective 10/25/2014 documents:Policy:In order to maintain the residents' high level of independence, residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility and there is a prescriber's order to self-administer.Procedures:A. If the resident desires to self-administer medications, an assessment is conducted by the inter disciplinary team of the resident's cognitive(including orientation to time), physical, and visual…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview the facility did not ensure a clean environment for 1 (R67) of 1 Resident.*Food and debris were observed alongside and under the wheelchair cushion on 1/20/26, 1/21/26, & 1/22/26.Findings include:On 1/20/26, at 9:45 a.m., Surveyor observed R67 sitting in a wheelchair in R67's room with his head down. R67 looked at Surveyor and then put his head back down. Surveyor observed the right side of R67's wheelchair, between the cushion and the right side, has a large accumulation of food particles and other debris.On 1/21/26, at 12:59 p.m., Surveyor observed R67 sitting in the wheelchair with an overbed table in front of him in R67's room. Surveyor observed on the right side of R67's wheelchair, between the cushion and the right side there is a large accumulation of food particles, including scrambled eggs, and other debris.On 1/22/26, at 10:58 a.m., Surveyor observed Certified Nursing Assistant (CNA)-Q, CNA-O, and Licensed Practical Nurse/Wound Nurse (LPN/WN)-T in R67's room. CNA-Q placed the sit to stand lift in front of R67 and CNA-O placed R67's feet…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility did not ensure 1 (R25) of 5 residents were free from chemical restraints.R25 was prescribed Seroquel 25 mg (milligrams) twice daily, an antipsychotic medication, on 11/5/25 after R25's family voiced concerns about R25 yelling and swearing. The facility did not attempt any nonpharmacological interventions and did not rule out any underlying medical conditions.Findings include:The facility's policy titled, Use of Psychotropic Medication(s) and not dated documents under policy It is the intent of this policy to ensure that residents only receive psychotropic medication when other nonpharmacological interventions are clinically contraindicated. Additionally, these medications should only be used to treat the resident's medical symptoms and not used for discipline or staff convenience, which would deem it a chemical restraint. Under police explanation and compliance guidelines include documentation of 5. The indications for initiating, maintaining, or discontinuing medication(s), as well as the use of non-pharmacological…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not ensure 3 (R2, R35, and R34) of 3 residents and/or representative were notified of the reason for transfer/discharge in writing and the facility bed hold notice did not contain the required information for appeal rights. *R2 was discharged to the hospital on 8/6/25, 10/21/25, and 12/7/25. The facility's transfer and discharge notice was not provided in writing and in a language understood to R2 and/or R2's representative. The facility bed hold notice does not contain the email address for all 3 agencies listed and the ombudsman information does not include an address. The facility was not able to provide documentation that bed hold/transfer notice was provided to R2 and/or representative for R2's discharge on [DATE]. *R35 was discharged to the hospital on 8/19/25 and 12/2/25. The facility's transfer and discharge notice was not provided in writing and in a language understood to R35 and/or R35's representative. The facility was not able to provide…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility did not ensure 1 (R2) of 4 Residents reviewed with limited range of motion, received appropriate treatment and services to increase range of motion/mobility and/or to prevent further decrease in range of motion/mobility.*R2 was observed not wearing a right hand splint to prevent further decrease in range of motion/mobility. Findings include:The facility's undated Use of Assistive Devices policy and procedure documents:Policy: The purpose of this policy is to provide a reliable process for the proper and consistent use of assistive devices for those residents requiring equipment to maintain or improve function and/or dignity .Policy Explanation and Compliance Guidelines:2. The use of assistive devices will be based on the resident's comprehensive assessment, in accordance with the resident's plan of care.4. Facility staff will provide appropriate assistance to ensure that the resident can sue the assistive devices. This may include education or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure 2 (R25 & R34) of 6 residents received adequate supervision and assistance devices to prevent accidents.*R25 was observed without a fall mat and body pillow while in bed according to R25's plan of care.*R34's falls on 8/12/25, 10/24/25, 11/23/25, 12/13/25, & 1/3/26 were not thoroughly investigated and the root cause was not consistently determined to help prevent further falls.Findings include:The facility's undated policy titled, Fall Prevention Program documents: Each resident will be assessed for fall risk and will receive care and services in accordance with their individual level of risk to minimize the likelihood of falls.1.) R25's diagnoses includes chronic kidney disease (kidneys are damaged and cannot filter blood & waste effectively), diabetes mellitus (high blood sugar), anxiety disorder (group of mental health conditions characterized by excessive and persistent worry, fear, and nervousness that can interfere with daily life),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure ongoing communication with the dialysis center and monitoring for complications before and after dialysis treatment for 2 (R34 & R11) of 2 residents reviewed for hemodialysis. Findings include: The facility's undated policy, titled Hemodialysis documents: The facility will assure that each resident receives care and services for the provision of hemodialysis consistent with professional standards of practice. This will include: *The ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility. *Safe administration of hemodialysis at the bedside in the nursing home provided by qualified trained staff/caregivers, in accordance with State and Federal laws and regulations: (see home dialysis treatment policy). *Ongoing assessment and oversight of the resident before, during and after dialysis treatments, including monitoring of the resident's condition…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility did not ensure residents received the necessary behavioral health care and services to maintain the highest practical mental and psychosocial well being in accordance with a comprehensive assessment and plan of care for 1 (R69) of 1 resident received for mood concerns.R69 has a long history of suicidal ideations. On 9/3/25 and 1/19/26, R69 voiced suicidal ideations while in the dining room. R69 was not placed on a one to one according to R69's plan of care, R69's physician and/or psychological services were not notified, and social service staff was unaware of these suicidal ideations.Findings include:The facility's undated policy titled, Suicide Prevention documents: It is the policy of this facility to act quickly and appropriately if a resident expresses thoughts of suicide. Under policy explanation and compliance guidelines documents 1. All staff members will immediately report any suicidal ideation to the resident's charge nurse and facility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated or the resident has already been immunized during this time period and each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized for 2 of 5 (R9 and R35) residents reviewed for immunizations. Findings include:The facility policy titled Influenza Vaccination (which is not dated) documents:. It is the policy of this facility to minimize the risk of acquiring, transmitting or experiencing complications from influenza by offering our residents, staff members and volunteer workers annual immunization against influenza.2. Influenza vaccinations will be routinely offered annually from October 1st through March 31st unless such immunization is medically contraindicated, the individual has already been immunized during this…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on facility policy review, record review, facility document review, and interview, the facility failed to report an incident of resident-to-resident abuse to the state survey agency within the required timeframe for 1 of 3 allegations of abuse reviewed. Specifically, the facility failed to report an incident of physical abuse between R1 and R2 within two hours of the witnessed incident.Findings included:A facility policy titled, Abuse, Neglect, and Exploitation, dated 10/01/2022, indicated, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The policy revealed, VII. Reporting/Response included, A. The facility will have written procedures that include, which included, 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g.[exempli gratia; for example], law enforcement when…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on facility policy review, record review, facility document review, and interview, the facility failed to complete a thorough investigation for 1 of 3 allegations of abuse reviewed. Specifically, the facility failed to obtain interviews or retain documentation of interviews from witnesses to an incident of resident-to-resident abuse involving R1 and R2.Findings included:A facility policy titled, Abuse, Neglect, and Exploitation, dated 10/01/2022, indicated, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The policy revealed, V. Investigation of Alleged Abuse, Neglect and Exploitation included A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. The policy continued, B. Written procedures for investigations include, which included, 4. Identifying and interviewing all…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not complete and transmit a discharge assessment as required for 1 (R1) of 2 residents reviewed for Minimum Data Set (MDS) assessments and transmission.R1 did not have a discharge assessment completed or transmitted after discharging from the facility on 9/1/2025.Findings include:The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.19.1 dated October 2024 (the RAI Manual) documents all Medicare and/or Medicaid-certified nursing homes must transmit required MDS data records to the Centers for Medicare and Medicaid Services' (CMS') Internet Quality Improvement Evaluation System (iQIES). Required MDS records include admission, quarterly, annual, and discharge assessments and entry tracking records. A discharge assessment refers to an assessment required on resident discharge from the facility. The RAI documents the discharge assessment is to be completed no later than the discharge date plus 14 calendar days. R1 was admitted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the Facility did not ensure a resident with a gastrostomy tube received the appropriate care and services for 1 (R3) of 3 residents reviewed with gastrostomy tubes. R3 had an enteral feed order for: Jevity 1.5, 65mL/hour X 20 hours. Off at 10:00AM and restart at 1400 (2:00PM). Surveyor had observations of R3's tube feed running between 10:00AM -2:00PM and was not turned off. R3 did not have monitoring, treatment, or care interventions in place for R3's G-tube site.Findings include:The facility policy titled Gastrostomy (G-tube) . Care Policy reviewed/ revised on 5/1/2025 documents: Purpose: To ensure safe, consistent, and evidenced-based care for residents with gastrostomy (G-tube) . feeding tubes, maintaining patency, preventing infection, and supporting adequate nutrition and hydration. Policy Statement: It is the policy of this facility to provide comprehensive care for residents with G-tubes . per physician orders, current standards of nursing practice, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record, the facility did not ensure 1 (R7) of 1 residents were assessed by the interdisciplinary team to determine it was clinically appropriate to self-administer medication.On 8/12/25, LPN-C was observed leaving R7's medication on the over bed table without observing R7 take her medication. R7 did not have an assessment to self-administer medications.Findings include:The facility's policy titled, Self-Administration of Medications and dated 10/25/14 under Policy documents In order to maintain residents' high level of independence, residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility and there is a prescriber's order to self-administer. Under Procedures documents A. If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive (including orientation to time), physical, and visual ability to carry out this…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure 1 (R1) of 3 resident's reviewed for hospitalization were allowed to the facility after they were hospitalized .*R1 was hospitalized on [DATE] and was denied readmission to facility. The facility did not effectively implement a discharge plan for R1 to include the timely and appropriate 30-day discharge notice providing the basis for R1's discharge nor did the facility provide coordination to find a safe transfer.Findings include:The facility's policy titled, Bedhold Notice Upon Transfer, dated [DATE], documents in part. POLICY: At the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident and/or the resident representative written notice which specifies the duration of the bed-hold policy and addresses information explaining the return of the resident to the next available bed.Policy Explanation and Compliance Guidelines: Bed Hold Notice Upon Transfer: . 3. The facility must permit each resident to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure 2 (R1 and R2) of 3 resident's reviewed for hospitalization received the proper notice of transfer and bed-hold to include; date and reason for transfer, location of transfer, duration of bed hold, appeal rights, and name and address (including mail and email) with the telephone number of the Office of the State Long-Term Care Ombudsman. * R1 was transferred to the hospital on 5/3/25, 6/6/25 and 6/9/25 and transfer and bed-hold notice was not given to R1 and/or R1's representative. *R2 was transferred to the hospital on 7/20/25 and transfer and bed-hold notice was not given to R2 and/or R2’s representative. Findings include: The facility’s policy titled, “Bedhold Notice Upon Transfer,” dated 3/1/19, documents in part… POLICY At the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident and/or the resident representative written notice which specifies the duration of the bed-hold policy and addresses…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not develop a comprehensive person-centered care plan to include measurable objectives and timeframes to meet the nursing needs for 2 (R4, R6) of 7 residents reviewed. *R4 did not have a comprehensive person-centered care plan developed to address R4’s urinary incontinence *R6 did not have a comprehensive person-centered care plan developed to include timeframes for how staff will meet R6’s urinary incontinence needs Findings include: The facility policy titled “Comprehensive Care Plans” dated 10/1/22 documents: . It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident’s medical, nursing, and mental and psychosocial needs that are identified in the resident’s comprehensive assessment… The care planning process will include an assessment of the resident’s strengths and needs… The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure there was a medication error rate below 5 percent. There were 2 medication errors in 34 observed opportunities which resulted in a medication error rate of 5.88%. Two medication errors were identified for R7.R7's Humalog insulin pen was not primed prior to dialing the amount of insulin R7's physician ordered. R7's Glargine insulin pen was not primed prior to dialing the amount of insulin R7's physician ordered, and the insulin pen was not dated when opened.Findings include:The facility's policy titled, Insulin Pen and not dated under Policy documents It is the policy of this facility to use insulin pens in order to improve the accuracy of insulin dosing, provide increased resident comfort, and serve as a teaching aid to prepare residents for self-administration of insulin therapy upon discharge. Under Policy Explanation and Compliance Guidelines documents 2. Insulin pens must be clearly labeled with the resident's name, physician…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not ensure 2 (R3 & R4) of 5 residents were free of significant medication errors.*R3 was admitted to the facility on [DATE] & discharged on 7/15/25. The after visit summary & Discharge summary dated [DATE] documents bacitracin-polymyxin B ophthalmic ointment with instructions to place into R3's right eye every 12 hours. The facility did not process this physician order and R3 did not receive bacitracin-polymyxin B ophthalmic ointment. R3 missed 10 doses of this medication.*On 12/10/24, R4's Humulin R 8 units before meals and Potassium & sodium phosphates 280-150-250 mg (milligrams) two packets twice daily documented in the hospital after visit summary & discharge summary was not processed by facility staff. R4 missed 8 doses of Humulin R and 6 doses of Potassium & sodium phosphates.Findings include:1.) R3 was admitted to the facility on [DATE] with diagnoses which includes congestive heart failure (chronic condition in which the heart doesn't pump blood as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based in interview and record review the Facility did not ensure 1 (R2) of 3 residents received treatment and care in accordance with professional standards of practice, the comprehensive person centered care plan and the resident's choice. R2 was admitted on [DATE] with a history of diverticulosis and constipation. R2 did not have a care plan initiated for bowel monitoring or interventions. R2 did not have documentation of bowel elimination until 3/10/2025 and R2 did not have a bowel movement documented until 3/12/2025 which was diarrhea and R2 had complaints of nausea. R2 was not assessed and there was no documentation regarding R2 was having nausea and diarrhea. On 3/13/2025 R2 went to the Hospital for further evaluation for complaints of nausea and abdominal cramping and a CT scan showed R2 had moderate colonic stool burden with mildly distended rectal vault. R2 was readmitted to the facility on [DATE] with recommendations to increase R2's laxative to two times a day and add MiraLAX daily, these…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility did not ensure that residents who are incontinent of bowel and bladder receive appropriate treatment and services to prevent skin-related complications for 1 of 2 (R3) residents reviewed for bowel and bladder. R3 admitted to the facility with pressure injuries and Moisture Associated Skin Damage (MASD). A care plan was not implemented to manage R3's incontinence. Findings include: R3 admitted to the facility on [DATE] and has diagnoses that include severe hypoxic ischemic encephalopathy, Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure with hypoxia, anoxic brain damage, Cerebral Infarction, Heart Failure, Major Depressive Disorder, spondylosis lumbosacral region, Hidradenitis Suppurativa and Epilepsy. The facility policy titled Continence and Incontinence - Assessment and Management review date 1/2025 documents (in part) . . Policy Statement 1. The staff and practitioners will appropriately screen for, and manage, individuals with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility did not ensure 1 (R8) of 4 residents reviewed for accidents received adequate supervision and assistance devices to prevent residents from sustaining falls. On 12/22/24, at 6:50 am, R8 sustained an unwitnessed fall and was found by facility staff lying on the floor with his left arm stuck in his bed rail. The facility did not complete a bed rail assessment prior to R8 having bed rails (cross-reference F700). The facility did not complete a thorough fall investigation, determine a root cause for his fall, complete reassessments to determine if bed rails continue to be appropriate for R8, and create a care plan with interventions in a timely manner. Findings include: The facility's Fall Risk Assessment that is not dated, documents: Each resident will be assessed for the risks of falling and will receive care and services in accordance with the level of risk to minimize the likelihood of falls. 1. The facility utilizes a standardized risk assessment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not assess the risk of entrapment and review the risks and benefits for 1 (R8) of 1 residents observed having bed rails. R8, who is dependent on staff for mobility, was observed to have a half side rail/grab bars on both sides of the bed and did not have a completed side rail risk assessment. Findings include: The facility's Bed Rail Policy dated 10/1/22, documents it is the policy of the facility to utilize a person-centered approach when determining the use of bed rails. Appropriate alternative approaches are attempted prior to installing or using bed rails. If bed rails are used, the facility ensures correct installation, use, and maintenance of the bed rails. As part of the resident's comprehensive assessment, the following components will be considered when determining the resident's needs, and whether or not the use of bed rails meet those needs. The resident assessment must include an evaluation of the alternatives that were attempted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interview, the facility did not ensure an RN (Registered Nurse) worked at the facility for at least eight consecutive hours a day, seven days a week, on 17 of 152 days reviewed. The facility also did not ensure a charge nurse was designated for shifts. * The facility did not have an RN (Registered Nurse) working in the facility for at least eight consecutive hours on 4/14, 4/20, 4/27, 5/12, 5/18, 6/1, 6/9, 6/15, 6/29, 7/4, 7/7, 7/13, 7/14, 7/20, 7/21, 7/28 and 9/2/2024. This deficient practice had the potential to affect all of the residents residing at the facility from April 1st through July 31st, 2024, and September 1st through September 30, 2024. * The facility did not ensure a charge nurse was assigned for each shift. This has the potential to affect all 76 residents residing in the facility at the time of the survey. Findings include: 1.) In preparation for the recertification survey, the Surveyor reviewed the PBJ report with a run date of 9/3/2024. (Payroll Based Journal reporting is a system that requires nursing homes to submit staffing data…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility did not ensure the facility assessment was updated to include the details regarding the water management committee, the infection preventionist and infectious disease management. This has the potential to affect all 76 residents residing in the facility. *The Facility Assessment lacked infection prevention and water management information. Findings include; On 10/03/24, at 11:22 AM, Surveyor reviewed the Facility Assessment for the water management committee, infection preventionist and hours devoted to program, and a section on infectious disease management. Surveyor notes nothing was listed for water management, infection preventionist or infectious disease management. (Cross-reference F880). On 10/07/24, at 09:02 AM, Surveyor interviewed Director of Nursing (DON)-B regarding the Facility Assessment lacking infection prevention and water management information. DON-B states they recently redid the Facility Assessment with a new update and accidentally omitted the information. On 10/07/24, at 10:42 AM, Surveyor spoke with DON-B who asked what needs to be in the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the Facility did not establish and maintain an infection prevention and control program based upon current standards of practice, designed to provide a safe environment and to help prevent the development and transmission of communicable diseases and infections. This deficient practice has the potential to affect all 76 residents. Additionally, 1 (R450) of 1 residents reviewed for medication administration had their medication handled bare handed by a nurse during preparation. *The Facility's Water Management Plan (WMP) was not based on current standards of practice and did not: -Reflect changes in program members, last updated June 2023. -Include the Facility's Infection Preventionist (IP). -No meetings were held related to WMP, only updates given to Quality Assurance Team of No infections related to Water Management -Have current water testing for Legionella, last test was 6/28/2023. *The Facility's Surveillance of the Infection and Control Program tracking was not accurate as the list did not accurately include residents as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interview, the facility did not ensure that 5 of 5, CNAs (Certified Nursing Assistants) reviewed completed the required annual 12 hours of educational training hours. Findings include: 1. On 10/8/24 at 1:45 PM, Surveyor reviewed the required educational training hours for CNA-C who was hired by the facility on. Surveyor noted that CNA-C had not completed the required 12 educational training hours in the last 12 months. Surveyor noted that CNA-C had only completed 8 hours of educational training hours in the last 12 months. 2. Surveyor reviewed the required educational training hours for CNA-D who was hired by the facility on. Surveyor noted that CNA-D had not completed the required 12 educational training hours in the last 12 months. Surveyor noted that CNA-D had only completed 7 hours of educational training hours in the last 12 months. On 1/17/2024 at 12:05 p.m., Surveyor informed NHA (Nursing Home Administrator)-A and DON (Director of Nursing) of the above findings. No additional information was provided as to why the facility did not ensure that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the Facility did not ensure the medical record contained signed advanced directive election forms for 1 (R71) of 18 residents reviewed. R71's Cardiopulmonary Resuscitation (CPR) advance directive election form Consent to CPR was not completed until [DATE], the day the Surveyor requested the information from the Facility. R71 had no care plan for advance directives completed. Findings include: The Facility Policy titled Resident's Rights Regarding Treatment and Advance Directives implemented [DATE] documents (in part): Policy: It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive . Policy Explanation and Compliance Guidelines: 1. On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive. 2. The facility will provide the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the Facility did not ensure that residents who require dialysis receive such services, consistent with professional standards of practice, including the ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility for 1 (R426) of 1 residents reviewed for dialysis. R426 was admitted to the Facility needing dialysis and did not have physician orders for hemodialysis and frequency of the dialysis. Assessments were not completed before or after dialysis sessions. No care plan was in place for monitoring and care of R426 related to dialysis and complications. There wasn't communication between the Facility and the dialysis center with each visit. Findings include: The Facility Policy titled Dialysis implemented 3/1/2019 documents (in part): Policy: This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the Facility did not ensure 2 residents (R7, R66) of 2 residents were properly assessed or risks explained for the use of bed rails. A routine maintenance and inspection schedule was not enforced by the Facility. *R7's Bed Rail Assessment was not updated since 1/25/2024 and Bed Rails Informed Consent for Use was not updated since 2/1/2024. R7's bed was observed to have grab bars on both sides of bed. *R66 has a right grab bar attached to bed frame but there is no evidence that risks were explained to R66 or their representative. *Routine maintenance and inspection of the grab bars was not documented or completed. Findings include: The Facility Policy titled, Proper Use of Bed Rails Date Implemented: 10/1/2022, documents in part: Policy It is the policy of this facility to utilize a person-centered approach when determining the use of bed rails. Appropriate alternative approaches are attempted prior to installing or using bed rails. If bed rails are used, the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based upon interview and record review, the facility's governing body failed to fulfill the responsibilities of the governing body to include establishing an implementing policies and procedures regarding the operations of the facility. This has the potential to affect all 75 residents present in the facility at the time of the survey. The facility's governing body did not ensure contracted vendors were reimbursed and paid in accordance with established contracts or invoiced amounts causing the facility's fiscal accounts to be in arrears. This has created the likelihood where good and services necessary to maintain operations of the facility along with care and treatment of the residents may be impacted by the failures of the governing body. Findings include: The facility Governing Body policy Implemented 3/1/23 documents: The facility will have a governing body, or designated persons functioning as a governing body, that is legally responsible for establishing and implementing policies regarding the management and operation of the facility. Policy Explanation and Compliance…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility did not ensure staff received annual QAPI (Quality Assurance and Performance Improvement) training for 4 of 5 Certified Nursing Assistants (CNA) reviewed. This practice had the potential to affect all 69 residents in the facility. The facility did not provide staff with the required annual QAPI training. Findings include: The Facility Policy titled Training Requirements implemented 10/1/2022, documents (in part) . Policy: . 5. Training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment. 6. Training content includes, at a minimum: . c. Elements and goals of the facility's QAPI program . 7. It is the responsibility of each employee, volunteer, or contract staff to complete required training. a. The facility offers a variety of training methods and times to accommodate individuals. b. An individual's failure to complete required training in a timely manner will result in termination of employment or contractual/volunteer…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure the accurate and safe administration of medication for 1 (R 7) of 1 residents reviewed for self-administration of medication. R7 was admitted to the facility on [DATE]. From 4/18/2024 through 5/3/2024, the facility documented that R7 was self-administering Entresto (a medication given to treat heart failure). R7 did not have a self-administration of medication assessment completed prior to administering Entresto. R7 did not have a physician's order to self-administer medication. R7 did not have a care plan regarding self-administration of medication. Findings include: The facility policy, entitled Self-Administration of Medications dated 10/25/14, documents, in part: In order to maintain the residents' high level of independence, residents who desire to self-administer medications are permitted to do so if the facility's Interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure a resident's right to privacy was maintained when receiving mail for 1 (R7) of 1 residents reviewed. R7's package was opened by facility staff without R7's permission. Findings include: The facility policy, entitled Communications within and external to the Facility dated 3/26/2023, documents, in part: The facility will protect and facilitate the resident's right to communicate with individuals and entities within and external to the facility . The facility will ensure the resident has the ability to send and receive mail, letters, packages and other materials delivered to the facility for the resident through a means other than a postal service . R7 was admitted to the facility on [DATE]. R7's admission Minimum Data Set (MDS) assessment, dated 4/24/2024, documents R7 is cognitively intact. R7 reported that R7's mail was delivered opened. On 6/27/24, at 8:40 AM, Surveyor interviewed Director of Nursing (DON)-B about R7's mail. DON-B stated that R7…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the Facility did not promptly investigate and resolve grievances for 3 (R16, R17, & R18) of 9 resident grievances reviewed. Findings include: The facility's policy titled, Grievance not dated under Preface documents The facility will ensure prompt resolution to all grievances, keeping the resident and resident representative informed throughout the investigation and resolution process. The facility grievance process will be overseen by a designated Grievance who will be responsible for receiving and tracking grievances through their conclusion, lead necessary investigations, maintaining the confidentiality of all information associated with grievances, communicate with residents throughout the process to resolution and coordinate with other staff (including the Administrator, if he or she is not the designated Grievance Official) and with state of sic (or) federal agencies as may indicated by specific allegations. Under G. Response includes documentation of Upon receipt of a grievance or concern, the Grievance Official will review the grievance,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility did not report 2 (R10 & R3) of 6 incidents to the State survey agency and/or Nursing Home Administrator during the required timeframe. * An allegation of sexual assault involving R10 was not reported to the Administrator and the State agency immediately but not later than 2 hours after the allegation was made. * An allegation of physical abuse involving R3 was not reported to the State Survey agency within 2 hours of the allegation being made. Findings include: The facility's policy titled, Abuse/Neglect/Exploitation and not dated under VII. Reporting/Response documents A. The facility will have written procedures that include: 1. Reporting all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g. law enforcement when applicable) within specified timeframe's: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the Facility did not have evidence allegations of abuse, misappropriation of property & mistreatment were thoroughly investigated for 3 (R10, R15, & R11) of 6 Residents reviewed for abuse. * The facility did not thoroughly investigate R10's allegation of sexual assault. * The facility did not thoroughly investigate R15's allegation of missing $416 and CNA-GG not assisting R15 with toileting. * The facility did not thoroughly investigate R11's allegation of neglect. Findings include: The facility's policy titled, Abuse/Neglect/Exploitation and not dated under section V. Investigation of Alleged Abuse, Neglect and Exploitation documents A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigation include: 1. Identifying staff responsible for the investigation; 2. Exercising caution in handling evidence that could be used in a criminal investigation (e.g.,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that 1 (R7) of 7 residents reviewed for ADL (Activities of Daily Living) assistance received the necessary services to maintain ability to practice good grooming and personal hygiene. R7 had no documented showers provided by facility staff from 4/18/2024 through 5/19/2024. Findings include: R7 was admitted to the facility on [DATE] and was discharged on 5/19/2024. R7 has diagnoses that include Right arm fracture, Muscle weakness, Morbid obesity, Depression, Anxiety and Type 2 Diabetes. R7's admission Minimum Data Set (MDS) assessment, dated 4/24/2024, documents R7 is cognitively intact. When asked, How important is it to you to choose between a tub bath, shower, bed bath or sponge bath? R7 answered somewhat important. R7's Care Area Assessment (CAA) dated 4/24/2024 documents R7 requires substantial/maximal assistance to shower/bathe self. R7 reported not receiving a shower or having her hair washed despite asking facility staff. Surveyor reviewed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the Facility did not ensure each Resident received adequate supervision to prevent accidents for 1 (R10) of 5 Residents. R10's fall interventions of body pillow to the side closest to the door and call light within reach were not observed when R10 was in bed during multiple observations. Findings include: R10's diagnoses includes hemiplegia and hemiparesis following cerebral infarction affecting left non dominate side, hypertension, and left & right above knee amputation. The at risk for falls care plan initiated 2/15/24 documents the following interventions: * Assess that wheel chair is of appropriate size; assess need for footrests; assess for need to have wheelchair locked/unlocked for safety. Initiated & revised 2/15/24. * Call light and personal items available and in easy reach or provide reacher. Initiated & revised 2/15/24. * Encourage participation in activities to improve strength or balance. Initiated & revised 2/15/24. * Keep environment well lit and free of clutter. Initiated & revised 2/15/24. * Keep personal items within reach.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not ensure 1 (R7) of 1 residents reviewed for respiratory care received such services consistent with professional standards of practice, comprehensive person-centered care plan and the residents' goals and preferences. R7 did not have MD (Medical Doctor) orders documenting the settings or cleaning of a CPAP (Continuous Positive Airway Pressure) machine per the facility policy. R7 did not have a Care Plan addressing the CPAP machine. Findings include: The undated facility policy, entitled CPAP system use or suspected OSA (Obstructive Sleep Apnea) documents, in part: Purpose-To identify proper patient selection in the use of Continuous Positive Airway Pressure . A physician's order for CPAP must include: an order for the device with settings or home settings per order, when the device will be used, cleaning schedule . Monitoring-The nurse will assess the patient and system and provide documentation. The nurse should note: .Respiratory rate . [Oxygen level] .…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the Facility did not ensure 2 (R8 and R9) of 4 residents were free from significant medication errors. *R8 had a MD (medical doctor) order to receive Tacrolimus (a medication to prevent rejection of a transplanted organ) 2 times a day. R8 did not receive 6 administrations during the first 5 days of R8's admission to the facility. *R9 had a MD order to receive Ivabradine (a medication to treat heart failure) 2 times a day. R9 did not receive 9 administrations of Ivabradine from 1/4/2024 through 1/9/2024. Findings include: The facility policy titled, Unavailable Medication dated 10/25/2014, documents, in part: Medications used by residents in the nursing facility may be unavailable for dispensing from the pharmacy on occasion . The facility must make every effort to ensure that medications are available to meet the needs of each resident . The pharmacy staff shall: 1) Call or notify nursing staff that the ordered product(s) is/are unavailable. 2) Notify nursing when it is…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility did not maintain records that were accurately documented for 1 (R10) of 15 residents reviewed. R10's diagnoses includes diabetes mellitus and right & left above knee amputation. There is a doctors order dated 4/4/24 for diabetic foot checks and starting on 4/4/24 licensed nursing staff were checking and initialing on the April, May, & June 2024 MAR (medication administration record) diabetic foot checks were being done when R10 does not have feet. Findings include: The facility's policy titled Documentation in the Medical Record and not dated under policy documents Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. R10's diagnoses includes diabetes mellitus and right & left above knee amputation. The physician's order dated 4/4/24 documents Diabetic foot checks daily at HS (hour sleep) at bed time. Review of R10's April MAR (medication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, observation and record review, the facility did not ensure 1 (R1) of 4 residents reviewed for quality of care received with treatments and care provided to facility residents. R1 was having pain across his chest and his rib area. R1 was given Tylenol by Med Tech (MT)-D. Med Tech-D did not alert a Registered Nurse to assess the resident's cardiac status, did not obtain vital signs and did not ask the resident what level of pain (on a 0 to 10 scale) he was at. MT-D charted that the medication was effective but he did not return to the resident to ask the resident if the medication was effective. No MD was updated on the resident's chest pain and possible change of condition. Findings include: Surveyor reviewed facility's Notification of Changes Policy with an implementation date of 3/1/19. Documented was: POLICY It is the policy of this facility that changes in a resident's condition or treatment are immediately shared with the resident and/or the resident representative, according to their authority, a reported to the attending physician or delegate (hereafter…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility did not ensure that 1 (R1) of 3 residents reviewed for medications were adequately monitored for Warfarin side effects. R1 was admitted to the facility with an order for Warfarin daily. The facility did not implement a care plan or orders to monitor for any adverse side effects that could result from taking an anticoagulant. Findings include: Surveyor reviewed facility's High Risk Medications - Anticoagulants with an implementation date of 3/1/19. Documented was: POLICY This facility recognizes that some medications, including anticoagulants, are associated with greater risks of adverse consequences than other medications. This policy addresses the facility s collaborative, systematic approach to managing anticoagulant therapy for efficacy and safety . Policy Explanation and Compliance Guidelines: 1. Anticoagulants shall be prescribed by a physician or other authorized practitioner with clear indications for use. Examples include prevention and treatment of deep vein thrombosis, pulmonary embolism, atrial fibrillation with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record reviews, the facility failed to formulate a comprehensive care plan for 2 of 11 sampled residents (R6 and R8). Findings include: Review of the facility policy titled, .Comprehensive Care Plans dated 10/01/22, stated It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment .All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care .The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment . 1. R6 was admitted to the facility on [DATE] with a primary diagnosis of encounter for surgical aftercare following surgery on the skin and subcutaneous tissue, with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure quality of care for 2 of 11 sampled residents (R6 and R7). Specifically, the facility failed to ensure R6 received wound care services and laboratory services, and the facility failed to follow physician orders for R7's pain medication. Findings include: 1. R6 was admitted to the facility on [DATE] with a primary diagnosis of encounter for surgical aftercare following surgery on the skin and subcutaneous tissue, with comorbidities of pressure ulcer of sacral region stage 4, bacteremia, sepsis, colostomy status, and neuromuscular dysfunction of bladder. R6's Minimum Data Set (MDS) dated [DATE], revealed the resident had a BIMS score of out 14 of 15 indicating she was cognitively intact. R6 also was noted to have a stage four pressure ulcer to the sacral area. Review of R6's Care Plan initiated on 12/21/23 included pressure ulcer offloading, skin assessments, turning and repositioning, weekly wound assessments, and treatments as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record reviews, and review of the policy, the facility failed to ensure 1 of 11 sampled residents (R7) received toileting care as needed to maintain continence level as assessed on admission. Findings Include: R7 was admitted to the facility on [DATE] with diagnosis of but not limited to age-related osteoporosis without current pathological fracture, neuromuscular scoliosis, lumbosacral region, displaced transverse fracture of right patella, and radiculopathy. R7's Minimum Data Set, dated [DATE] a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R7 was cognitively intact. R7 was documented as dependent on toileting hygiene and transfer and was occasionally incontinent of urine. During an interview on 01/25/24 at 2:15 PM, R7 revealed she was continent of urine but had struggled with toileting since admission. R7 said that she was restricted because of her leg's immobility. She said staff would come in every two hours to offer her a bedpan for toileting. She said…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review and interviews, the facility failed to ensure that 1 of 9 sampled residents (R1) was provided appropriate assistance with transfers resulting in fall. Findings include: Review of R1 was admitted to the facility on [DATE] with a primary diagnosis of COVID-19, and comorbidities including morbid obesity, heart disease, peripheral vascular disease, and lymphoma. Review of R1's Minimum Data Set (MDS) dated [DATE] revealed RI was cognitively intact. The MDS also indicated he had bilateral lower extremity impairment, used a walker/wheelchair, with substantial/maximal assistance for toileting. The resident was also dependent on assistance with sitting to standing, and all transfers. Review of R1's Care Plan revealed he required two person assistance with all transfers with a wheeled walker and one person maximum assistance to complete toileting. Review of the facility's Investigation Report indicated on 09/22/23 at 10:30 PM CNA C (Certified Nursing Assistant) answered R1's call…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to ensure 2 of 9 sampled residents (R4 and R5) reviewed for treatment administration had complete and accurately documented medical records. Specifically, the facility failed to ensure treatment administrations for R4 and R5 contained accurate documentation of physician treatment orders. Findings include: Review of the undated facility policy titled, Documentation in the Medical Record, revealed Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation . Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred . 1. R4 was admitted to the facility on [DATE] with diagnoses of COVID-19, low back pain, and sepsis related to prior back surgery with surgical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2.) R95 was admitted to the facility on [DATE]. R95's physician order with a start date of 2/19/23 & end date of 2/20/23 documents Rapid Covid test day of admission, 48 hours after admission and 48 hours after one time a day for 1 Administration. R95's physician order with a start date of 2/21/23 & end date of 2/22/23 documents Rapid Covid test day of admission, 48 hours after admission and 48 hours after one time a day for 1 Administration. R95's physician order with a start date of 2/23/23 & end date of 2/24/23 documents Rapid Covid test day of admission, 48 hours after admission and 48 hours after one time a day for 1 Administration. The nurses note dated 2/20/23 at 10:19 a.m. documents Patient tested this morning for COVID. Patient tested positive. Patient and family member notified that patient has COVID. Surveyor reviewed the facility's COVID line list and noted R95 is not listed during February 2023 as being COVID positive. On 6/14/23 at 12:30 p.m., Surveyor spoke with LPN/UM-E who is the Infection…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure 1 (R6) of 17 sampled residents was given the right to formulate their preference regarding their code status and have the facility correctly reflect that preference. *R6 elected to be a full code upon admission to the facility on [DATE], a new document was initiated for Do Not Resuscitate (DNR) on [DATE] with DNR physician's orders. The electronic medical record contained conflicting details regarding R6's code status. R6 verbally expressed during survey they are to be a full code. Interviews with facility staff indicated the facility did not have an effective system to ensure residents are able to accurately formulate their code status and have it honored. Findings Include: Surveyor reviewed the facility Communication of Code Status policy and procedure implemented [DATE]. .Policy: It is the policy of this facility to adhere to Residents' rights to formulate advance directives. In accordance to these rights, this facility will implement…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the Facility did not ensure 1 (R22) of 17 sampled Residents reviewed had facility staff consult with the Resident's physician according to their physician orders. R22's physician orders for Januvia 50 mg (milligrams) includes to call MD (medical doctor) if blood sugar is less than 70 or greater than 400. On 6/9/23 R22's blood sugar was 67. There is no evidence R22's physician was consulted with when staff identified the low blood sugar. Findings include: R22's diagnosis includes Type 2 diabetes mellitus with diabetic chronic kidney disease. R22's physician orders include, with an order date of 5/25/23 documents, Januvia oral tablet 50 mg (Sitaglipin Phosphate). Give 1 tablet by mouth one time a day for DM2 (diabetes mellitus type two) call MD if BS (blood sugar)< (less than) 70 or > (greater than) 400. On 6/13/23, at 10:49 a.m., Surveyor reviewed R22's June 2023 MAR (medication administration record) and noted the blood sugar is documented as 67 with RN (Registered Nurse)-W's initials. Surveyor reviewed R22's medical record including progress…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the Facility did not ensure 1 (R6) of 1 Residents who received a facility initiated 30 day notice of discharge received a notice that contained the required contents. R6's 30 day notice of discharge included the incorrect address and phone number of the Division of Quality Assurance (DQA), Southeastern Regional Office, the incorrect information for the Division of Hearings and Appeals notification, and the 30 day notice incorrectly advises R6 to contact the Department of Human Services (DHS) for assistance with filing an appeal. Findings Include: Surveyor reviewed the facility's Transfer and Discharge policy and procedure dated 10/1/22 and notes the following applicable to 30 day discharge notices: .Policy Explanation and Compliance Guidelines: . 3. When a Resident exercises his/her right to appeal a transfer or discharge, the facility will not transfer or discharge the Resident while the appeal is pending, unless the failure to discharge or transfer would endanger the health…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record review, the facility did not ensure the PASARR (Pre-admission Screen and Resident Review) for 1(R6) of 1 Residents reviewed for PASARR screening was completed accurately and referred for a Level II screen when a change in status occurred. *R6's Pre-admission Screen and Resident Review (PASARR) dated 9/10/20 does not accurately document R6's mental disorders and current medications used for treatment upon admission to the facility. R6's PASARR was not updated when the facility identified R6's placement was going to exceed the 30 day exemption nor when R6's was evaluated by psychiatric services for hallucinations, and delusions and new mental disorder diagnoses were given thus resulting in an inaccurate screening. With an inaccurate Level I screen the facility did not refer R6 for a Level II screen. The Level II screen would determine whether a resident has a mental disorder (MD), intellectual disability (ID) or a related condition, determine the appropriate setting and what if any…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the Facility did not ensure a baseline care plan was developed and implemented within 48 hours of a Resident's admission for 3 (R22, R95, R97) of 17 Residents. * R22 was admitted to the facility on [DATE]. The Facility did not develop a baseline care plan for pain, pressure injuries, or falls. * R95 was admitted to the facility on [DATE]. The Facility did not develop a baseline urinary catheter care plan. * R97 was admitted to the facility on [DATE]. The Facility did not develop any baseline care plans. Findings include: The Baseline Care Plan Policy implemented 3/1/19 under Policy Explanation and Compliance Guidelines documents: 1. The baseline care plan will: a. Be developed within 48 hours of a resident's admission. b. Include the minimum healthcare information necessary to properly care for a resident including, but not limited to: i. Initial goals based on admission orders. ii. Physician orders. iii. Dietary orders. iv. Therapy services. v. Social Services. vi.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not ensure resident's had a comprehensive plan of care related to clinical concerns. This was observed with 2 (R146 and R38) of 18 resident reviews. -R146 did not have a comprehensive plan of care for continuously removing their oxygen to include interventions, goals and timeframes. -R38 did not have a comprehensive plan of care for fall interventions with goals and timeframes. Findings include: 1.) R146 medical record was reviewed by Surveyor. R146 resided in the facility from [DATE] -11/3/22. R146 has physician orders to receive oxygen continuous for Chronic Obstructive Pulmonary Disease. R146's physician orders dated 10/15/22, indicates oxygen at 2.5 liters per minute per nasal cannula continuous for Chronic Obstructive Pulmonary Disease every shift. R146 Progress Notes from the medical record include the following: - On 11/3/2022, at 10:45 AM, [R146] was noted with oxygen nasal cannula off on multiple occasions during the morning oxygen [sic] and [R146]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility did not develop and implement an effective discharge planning process including involving the resident and resident representative in the development of the discharge plan and inform the resident and resident representative of the final discharge plan for 1 (R297) of 6 Residents reviewed for discharge planning. *R297 was discharged to another skilled nursing (SNF) facility on 6/4/22 without R297's activated Health Care Power of Attorney (HCPOA)'s authorization. On 6/3/22 the facility notified a family member of R297, not R297's Activated HCPOA, of the planned transfer of R297 to another SNF. R297's Activated HCPOA and/or interested family members were not involved in the discharge planning process including selection of the new SNF or ability to tour SNFs prior to agreement to transfer. Findings Include: Surveyor reviewed the facility's Transfer and Discharge, policy and procedure dated 10/1/22, and notes the following applicable: . 9. The facility will not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure that 1 (R6) of 5 residents reviewed for ADL (Activities of Daily Living) assistance received the necessary services to maintain good grooming and personal hygiene. *R6 had no documented showers provided by facility staff per their plan of care. Findings include: R6 was admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, injury of unspecified nerve at shoulder and upper arm level, left arm, subsequent encounter, other specified disorders of muscle, chronic obstructive pulmonary disease as well as obsessive-compulsive disorder, anxiety disorder, unspecified, and major depressive disorder. R6's most recent MDS (Minimum Data Set) documents a BIMS (Brief Interview for Mental Status) score of 15, indicating that R6 is cognitively intact. Section G (Functional Status) documents that R6 requires total assistance and one-person physical assist for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the Facility did not ensure 1 (R95) of 2 Residents reviewed received appropriate treatment and services related to catheter care. *R95's medical record did not have any physician orders for R95's urinary catheter, there is not a diagnoses, size of the catheter, or any catheter care to be provided. Findings include: The Appropriate Use of Indwelling Catheter policy not dated under Policy Explanation and Compliance Guidelines documents 4. The use of an indwelling urinary catheter will be in accordance with physician orders, which will include the diagnosis or clinical condition making the use of the catheter necessary, size of the catheter, and frequency of change (if applicable). R95 was admitted to the facility on [DATE] and discharged to the hospital on 2/21/23. Diagnoses includes hydronephrosis with ureteropelvic junction obstruction, urinary retention, and benign prostatic hyperplasia. The Clinical admission Evaluation dated 2/19/23 under Genitourinary section documents…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility did not ensure that residents who need respiratory care are provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for for 2 of 2 (21 and R22) residents reviewed for respiratory care. R21 and R22 have a CPAP (Continuous Positive Airway Pressure) machine in their room. Neither resident had Physician's orders or a care plan for the CPAP. Findings include: 1,) R21 admitted to the facility on Admit 4/28/23 and has diagnoses that include acute Respiratory Failure with hypercapnia, Asthma, Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure with hypoxia, acute systolic Congestive Heart Failure and morbid obesity. R21's Care Plan Focus area documented: Alteration in Respiratory Status Due to Impaired Gas Exchange - date initiated 4/30/23. Interventions: - Administer medications as ordered. Observe Labs, response to medication and treatments.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility did not ensure pain management was provided to Residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 Resident (R) (R6) of 3 sampled Residents who was experiencing pain. *R6's pain is not effectively managed through assessment, intervention, non-pharmacological interventions, and Resident advocacy to control R6's identified pain. Findings Include: R6 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction Affecting Left-Dominant Side, Sleep Apnea, Insomnia, Other Idiopathic Calliopsis, Chronic Obstructive Pulmonary Disease, Major Depressive Disorder, Anxiety Disorder, Other Obsessive-Compulsive Disorder, Unspecified Attention-Deficit Hyperactivity Disorder, and Other Psychoactive Substance Abuse. R6 is currently R6's own person. R6's 5-day Minimum Data Set (MD'S) dated 5/26/23 documents R6's Brief Interview…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the Facility did not ensure consistent communication for 1 (R97) of 1 Residents who receive dialysis services. R97's dialysis/observation communication forms were either missing or incomplete. Findings include: The Dialysis policy implemented 3/1/19 under Policy Explanation and Compliance Guidelines documents 2. The care plan will reflect the coordination between the facility and dialysis provider and will identify nursing home and dialysis responsibilities. 4. Nursing staff will provide a report to the dialysis provider regarding the resident's condition and treatment provisions each dialysis treatment day, and as needed. R97 was admitted to the facility on [DATE]. Diagnoses includes end stage renal disease and dependence on renal dialysis. The physician orders dated 6/2/23 documents Dialysis Monday, Wednesday, Friday at [Dialysis Name]. The physician orders dated 6/3/23 documents Monitor left arm AV (arteriovenous) fistula for + (positive) bruit and thrill q (every) shift…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility did not ensure 2 (R6 and R38) of 2 residents reviewed for side rails had assessments for the need to use side rails, that consent was obtained for their use and that alternatives were attempted prior to installation. R6 and R38 were observed to have assist/side rails on their bed without assessments, and/or without care plans, consent, and without alternatives attempted. Findings Include: Surveyor requested a facility policy and procedure for re-positioning mobility bars. Surveyor notes the facility refers to re-positioning mobility bars as 'bed canes'. Surveyor reviewed the provided facility 'Proper Use of Bed Rails' policy and procedure dated 10/1/22 and notes the following applicable: .It is the policy of this facility to utilize a person-centered approach when determining the use of bed rails. Appropriate alternative approaches are attempted prior to installing or using bed rails. If bed rails are used, the facility ensures correct installation,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, and record review, the facility did not ensure R299 received pharmaceutical services (accurate acquiring, dispensing and administering of all drugs and biologicals) to meet the needs of each resident. Surveyor observed Pepto Bismal and fiber powder, on R299's bedside table and a non prescription sleep aide was located in R299's drawer. R299 did not have a physician's order for the Pepto Bismal, fiber power, and non-prescription sleep aide. R299 was assessed to not be able to safely self-administer medication. The Facility was not aware R299 was self-administering Pepto Bismal, fiber powder and non-prescription sleep aide until the Surveyor alerted the Facility of the concern. Findings Include: Surveyor reviewed the facility's Storage of Medications policy and procedure dated 3/17 and notes the following: . Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure 1 (R15) of 5 residents reviewed for unnecessary medications had adequate behavior monitoring on a consistent basis while receiving psychotropic medications. *R15 was receiving Seroquel for Dementia with Delirium; there is no indication facility staff were monitoring individual behaviors for R15 including symptoms of delirium. Findings include: R15 was admitted to the facility on [DATE]. R15 has a diagnoses of Unspecified Dementia without behavioral disturbance and cognitive communication deficit. A physician's order was initiated indicating: Seroquel Oral Tablet 25 MG (Quetiapine Fumarate): Give 1 tablet by mouth at bedtime for Dementia With Delirium. On 6/15/23, Surveyor reviewed R15's comprehensive care plan. R15's care plan initiated 5/30/23 indicates: Potential for drug related complications associated with use of psychotropic medications related to: Anti-Anxiety medication, Anti-psychotic medication. Care plan interventions…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.